/ SHARED SERVICES
Office of Payment Accuracy and Recovery
Overpayment Writing Unit /

Self-Sufficiency Overpayment Referral

Please submit this form to the Office of Payment Accuracy and Recoveryif you believe an overpayment of benefits may exist.Contact an overpayment writer in your area if you need assistance.

Case information
This referral is for potential overpayment on a: DHS client DHS childcare provider
Last name: / First name: / MI:
Date of birth: / Social Security number: / Prime number:
SNAP case number: / PA case number: / Case status:
Open Closed
Please complete each line below.
Your referral cannot be processed without this information.
*Programs of potential overpayment:SNAP TANF/ERDC / Medical:

*Type of potential overpayment: Agency error Client/provider caused

*Time period of potential overpayment: From:

/

To:

*If this overpayment referral is being made due to unreported or under-reported income, please

list the employer or source of income:
*If fraud is suspected, attach copies of applications for the overpayment time period.
*Describe the cause of the potential overpayment:(If referral is due to questionable household composition, please fill out the 371 and refer to FIU.)
Referred by: / Branch: / Date: / Phone number:

Submit this referral and any supporting documentation and/or benefit applications.
You may email this referral to: REFERRALS OVERPAYMENT()

Note: This form may contain personal information. If you return the form by e-mail there is some risk it could be intercepted by someone you did not send it to. If you are not sure how to send a secure e-mail, consider using regular mail or fax.

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You may mail or fax to the OPAR central office at
Postal mail:

OPAR OVP Referrals

PO Box 14150

Salem, OR 97309

/

Shuttle address:

OPAR OVP Referrals

3406 Cherry Ave NE

Salem, OR 97301

/ Phone:503-373-1872
Fax:503-373-1525
Toll free:1-877-888-3578
Seepage 2 for overpayment threshold information.

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If a potential overpayment does not meet the threshold, do not submit a referral.
Narrate the reasons for not submitting a referral in TRACS.Contact an overpayment writer if youhave questions.
Overpayment thresholds
(Effective 01/01/04)
Administrative error (AE) occurrences
• / Food benefit (SNAP)program – open case / More than $100
• / Food benefit (SNAP) program – closed case / More than $200
• / Cash (TANF) and child care (ERDC) programs / More than $200
• / Medical programs / No AE overpayments
Client error (CE) occurrences
• / Food benefit (SNAP) program – open case / More than $100
• / Food benefit (SNAP) program – closed case / More than $200
• / Cash (TANF) and child care (ERDC) programs / More than $200
• / Medical programs / More than $750
Possible fraud (PF) occurrences / No minimum amount
• / Refer all PF overpayments to an overpayment writer regardless ofthe
dollar amount.

Quality control review cases

/ No minimum amount
• / All referrals from quality control arereviewed regardless of dollar amount.
Refer all potential medical overpayments to the Overpayment Writing Unit, including medical transportation payments.

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